HomeMy WebLinkAbout12-015r
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(3 19) 356-5497 FAX
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
(Office Use Only)
First Mi de Last
1. Name /
2. Mailing Address q 1 S r Z
3. Telephone: Home q 3 I q% % Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? �Il?
Type of offense Where When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?. Cl
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 00
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years?
Type of offense Where When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
d.d .,d,wbadg 09/2010
I ha nbffI have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
d�,, . I understand that if I falsely answer any questions in this application, that As
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application may a denied. understand that if I falsely answer any of the questions in this application, that this application will
be denied. I agree that in making this application, I consent to allow agents or employees of the City of Iowa City, Iowa, in
their discretion, to examine any and all records and documents relating to this application, and I further agree that, if a license
is granted, to comply at all times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) q p
Signature of Applicant �jQ (/fi(M /� 1 �� �vyl Date 01-2012—
STATE
I2OIZ
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and swom to before me by �� �� ar m ; �� r \�� 5 0 On this day of
and for the State of Iowa
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Date
Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
d�bads 2010.a 09/2010
State of Iowa
Division of Criminal Investigation
215 E 7rs St
Des Moines IA 50319
Ph. 515-725-6066 Fax 515-725-6080
Iowa Criminal History Record Check
Walk -In Request
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name Apenido (mandatory)
First Name Primer Nombre (mandatory)
Middle Name Segundo Nombre (rewmmended)
p I
KA)JO Vi
M i c4ae
Date of Birth Fecha Nacimiento (mmdatory)
Gender c/nerd (mandatory)
Social SecurityNumber (recommended)
Gale []Female
"ev,L—
Waiver Si nature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.)
q VX AVS00
ai USE ONLY
Results
//��
As of I - I - / f- , a name and date of birth check revealed:
li
Vo record found
JJJJJJ❑Record
a the , DCI #
ti
DCI inials
Receipt �1
Number of requests __�_ x $15.00 per last name = Total amount $1� 11 U
Method of payment: -+ash ❑money order ❑check # []MasterCard or Visa
Cardholder's n ne Last 4 digits of MC or Visa
DCI initials
Credit Card Number # Exp. Date
a Iowa Department of Transportation
Office of Driver Services (Toll Free) 8W-532-1121
PO Box 9204, Des Prones, IA 503D&9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
1/18/2012
DL/ID #:
769YY0847(IA)
Customer #:
4292418
Name:
Allison, Kevan Michael
Class:
D
ID Status:
None
Address:
519 Church St
Audit #:
3925101
DL Status:
VAL
Issue Date:
12/04/2009
CDL Status:
None
City/State:
Iowa City, IA 52245
Expiration
11/29/2014
CDL Cert
None
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
519 Church St
Restrictions:
NONE
Restriction
None
Date of Birth:
11/29/1961
Supplement:
Mailing City/State:
Iowa City, IA 52245
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Allison, Kevan Michael DL/ID: 769YY0847
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby
certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of an
official record currently in the custody of said office, and that I have been authorized by the Director of the Iowa Department of
Transportation to so certify.
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
•.;w�'vl
1/18/2012
IOWAy'%
E �y
•
.......�;
Office of Driver Services
a&HIM
Iowa Department of Transportation
Name: Allison, Kevan Michael DL/ID: 769YY0847